Christine Nutbeam

1. 1. lack of information transfer between hospitals

   “Staff at St. Peter's Hospital did not contact Wexham Park Hospital to advise of the recent admission, treatment and symptoms even though they were on notice that Mrs [name redacted] had a follow up appointment at Wexham Park Hospital some two days later because they arranged that appointment. Concern is the apparent lack of any procedure to allow information to be transferred between different Trusts in different Counties. There was no letter given to Mrs [name redacted] to accompany her to the subsequent app”

2. 2. vomiting not recorded in nursing notes

   “Despite clear evidence from the family that Mrs [name redacted] was vomiting on the ward shortly before her debridement procedure, there is no reference in the nursing notes and this information was not made known to the Anaesthetist nor Surgeon. The fact that she was vomiting prior to a surgical procedure should have been a matter of serious concern”

3. 3. aspiration risk from undetected vomiting

   “The evidence given at the Inquest was that if the Anaesthetist/Surgeon had been aware of the vomiting symptoms, the procedure would have been deferred to investigate the cause of the vomiting. This may have prevented aspiration during the surgery”

4. 4. absence of vomiting inquiry before surgery

   “It was also given in evidence at the Inquest that, when the Anaesthetist visited Mrs [name redacted] prior to the surgery and explained the procedure, the risks and took her consent, he did not ask her if she had vomited within the last twenty four hours. The evidence was that this is not a standard question to ask of patients ahead of surgery”

5. 5. training gap in pre‑operative questioning

   “The question is posed as to whether this should become a standard question that is”

No published response was found on judiciary.uk.